scholarly journals Adrenal Vein Sampling to Distinguish Between Unilateral and Bilateral Primary Hyperaldosteronism: To ACTH Stimulate or Not?

2020 ◽  
Vol 9 (5) ◽  
pp. 1447
Author(s):  
Tae-Yon Sung ◽  
Wilson Mawutor Alobuia ◽  
Monica Varun Tyagi ◽  
Chandrayee Ghosh ◽  
Electron Kebebew
Keyword(s):  
Adrenocorticotropic Hormone ◽  
Primary Hyperaldosteronism ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
Successful Cannulation ◽  
Unilateral Disease ◽  
The Right ◽  
Lateralization Index ◽  
Prospective Database

The aim of this study is to determine the accuracy of adrenal vein sampling (AVS) with and without adrenocorticotropic hormone (ACTH) stimulation to distinguish between unilateral and bilateral primary hyperaldosteronism (PA). Retrospective analysis of a prospective database from a referral center between 1984 and 2009, 76 patients had simultaneous cannulation of bilateral adrenal veins and AVS with and without ACTH stimulation. All patients had adrenalectomies. The selectivity index (SI, cut-off value ≥2) was used for confirmation of successful cannulation of the adrenal vein. The lateralization index (LI, cut-off value >2 and >4) was used for distinguishing between unilateral and bilateral PA. The SI ratio was higher with ACTH stimulation compared to without for the right adrenal vein (p = 0.027). The LI > 2 ratio was higher with ACTH stimulation compared to without (p = 0.007). For the LI > 4 ratio, there was no difference between with and without ACTH stimulation (p = 0.239). However, for a LI > 4, 7 patients (9.2%) were not lateralized with ACTH stimulation, but they did lateralize without ACTH stimulation. AVS with ACTH stimulation is associated with a higher SI ratio compared to AVS without ACTH stimulation. However, when using LI > 4 for AVS, samples without ACTH stimulation should also be included to detect a subset of patients with unilateral disease that are not detected with ACTH stimulation.

scholarly journals Comparison of Bolus and Continuous Infusion of Adrenocorticotropic Hormone During Adrenal Vein Sampling

2021 ◽  
Vol 12 ◽  
Author(s):  
Jinbo Hu ◽  
Jiangqiong Chen ◽  
Qingfeng Cheng ◽  
Ying Jing ◽  
Jun Yang ◽  
...  
Keyword(s):  
Continuous Infusion ◽  
Adrenocorticotropic Hormone ◽  
Tertiary Hospital ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
Successful Cannulation ◽  
Infusion Group ◽  
Biochemical Remission ◽  
Cannulation Success

BackgroundAdrenocorticotropic hormone (ACTH) is widely used in adrenal vein sampling (AVS) and can be administered as a bolus injection or continuous infusion. The optimal administration method has not been determined. We aimed to compare the effects of ACTH bolus with infusion on cannulation success, lateralization assessment and adverse events (AEs).MethodsRetrospectively collected data from patients with primary aldosteronism who underwent AVS with ACTH at a tertiary hospital in China. Rate of successful cannulation, lateralization index (LI), complete biochemical remission and AEs related to AVS were analyzed.ResultsThe study included 80 patients receiving ACTH bolus and 94 receiving infusions. The rate of successful cannulation was comparable between bolus and infusion groups (75/80, 93.4% vs 88/94, 93.6%). In those with successful cannulation, the bolus group had a higher selectivity index than the infusion group, while LI [6.4(1.8-17.5) vs. 7.6(2.0-27.8), P=0.48] and rate of complete biochemical remission (43/44, 97.7% vs 53/53, 100%, P=0.45) did not significantly differ between the two groups. One in the bolus and one patient in the infusion group had adrenal vein rupture but they recovered with conservative treatment. The bolus group reported more transient AEs such as palpitation (52.9% vs 2.2%) and abdominal discomfort (40.0% vs 2.2%) than the infusion group.ConclusionsDue to their similar effects on cannulation success and lateralization, but a lower rate of transient AEs in the infusion group, the continuous infusion method should be recommended for ACTH stimulation in AVS.

scholarly journals Effect of Adrenocorticotropic Hormone Stimulation During Simultaneous Bilateral Adrenal Vein Sampling in Primary Aldosteronism

2021 ◽  
Vol 53 (06) ◽  
pp. 364-370
Author(s):  
Wei Liu ◽  
Jingjing Zhang ◽  
Yaling Yang ◽  
Yinxin Jin ◽  
Zaizhao Li ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Adrenocorticotropic Hormone ◽  
Base Excess ◽  
Serum Potassium Level ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
Before And After ◽  
Carbon Dioxide Combining Power ◽  
Lateralization Index

AbstractThe aim of the study was to investigate the significance and influence of adrenocorticotropic hormone (ACTH) stimulation in primary aldosteronism (PA) patients with simultaneous bilateral adrenal vein sampling (AVS). All patients diagnosed with PA underwent simultaneous bilateral AVS with ACTH. In 95 patients, the post-ACTH SI significantly increased (p<0.001), and it gradually decreased from t10–t30 after ACTH stimulation (p<0.001). The unsuccessful catheterization decreased after ACTH stimulation. Time points within 20 min after ACTH stimulation were better for sampling, and the selectivity did not increase over longer periods. According to lateralization before and after ACTH stimulation, the patients could be divided into 3 groups (U, unilateral; B, bilateral): U/U , U/B or B/U, and B/B. Compared with the U/U group, in the U/B or B/U and B/B groups, the lateralization index (LI) was lower both at baseline and after ACTH stimulation (p<0.0001), the contralateral index (CLI) was higher after ACTH stimulation (p<0.003), the serum potassium level was higher (p<0.001), and the carbon dioxide combining power (CO2CP) and base excess (BE) levels were lower. In conclusion, in simultaneous bilateral AVS, ACTH stimulation had significant effects on increasing the catheterization selectivity. Lateralization change was observed after stimulation. After ACTH stimulation, fewer patients could be diagnosed with lateralized PA. Patients with consistent lateralized PA showed a more serious phenotype.

scholarly journals An Alternative Method for Adrenal Venous Sampling in Cases in Which Right Adrenal Vein Sampling is Difficult

2022 ◽  
Author(s):  
Akira Yamamoto ◽  
Takeshi Fukunaga ◽  
Mitsuru Takeuchi ◽  
Hiroki Nakamura ◽  
Akihiko Kanki ◽  
...  
Keyword(s):  
Adrenocorticotropic Hormone ◽  
Inferior Vena ◽  
Vena Cava ◽  
Blood Sampling ◽  
Adrenal Vein ◽  
Threshold Values ◽  
Adrenal Vein Sampling ◽  
Alternative Method ◽  
Aldosterone Producing Adenoma ◽  
The Right

Abstract PurposeCatheterization of the right adrenal vein (rt.AdV) to obtain blood samples can often be difficult. The aim of the present study was to investigate whether blood sampling from the inferior vena cava (IVC) at its juncture with the rt.AdV can be an alternative to sampling of blood directly from the rt.AdV.Materials and MethodsThis study included 44 patients diagnosed with primary aldosteronism (PA) in whom AVS with adrenocorticotropic hormone (ACTH) was performed, resulting in a diagnosis of idiopathic hyperaldosteronism (IHA) (n=24), and patients diagnosed with unilateral aldosterone-producing adenoma (APA) (n=20; rt.APA=8, lt.APA=12). In addition to regular blood sampling, blood was also sampled from the IVC, as the substitute rt.AdV [S-rt.AdV]. Diagnostic performance with the conventional lateralized index (LI) and the modified LI using the S-rt.AdV was compared to examine the utility of the modified LI.ResultsThe modified LI of the rt.APA (0.4±0.4) was significantly lower than those of the IHA (1.4±0.7) (p<0.001) and the lt.APA (3.5±2.0) (p<0.001). The modified LI of the lt.APA was significantly higher than those of the IHA (p<0.001) and rt.APA (p<0.001). Sensitivity and specificity to diagnose rt.APA and lt.APA using the modified LI with threshold values of 0.7 and 2.2, respectively, they were 87% and 75%, respectively, and 94% and 94%, respectively.ConclusionThe modified LI has the potential to be an alternative method for rt.AdV sampling in cases in which rt.AdV sampling is difficult. Obtaining the modified LI is extremely simple, which might complement conventional AVS.

scholarly journals Laterality Diagnosis of Adrenal Vein Sampling for Primary Aldosteronism Using Aldosterone Alone

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A291-A291
Author(s):  
Norio Wada ◽  
Shuhei Baba ◽  
Hajime Sugawara ◽  
Arina Miyoshi ◽  
Shinji Obara ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Roc Analysis ◽  
Vena Cava ◽  
Area Under The Curve ◽  
Adrenal Vein ◽  
Acth Stimulation ◽  
Adrenal Vein Sampling ◽  
Left And Right ◽  
Lateralization Index

Abstract Background: In adrenal vein sampling (AVS) for primary aldosteronism (PA), cortisol concentration is used to determine successful AVS, and laterality diagnosis is performed using a combination of aldosterone and cortisol concentrations. In this study, we examined the comparison with the conventional method when AVS was determined by aldosterone alone. Subjects and methods: We studied the data from 277 patients with PA who underwent AVS in Sapporo City General Hospital from July 2007 to April 2020. The patients with autonomous cortisol production were excluded. Using the blood samples from adrenal veins and inferior vena cava (IVC) after ACTH stimulation, the predicting ability of the left and right ratio of aldosterone concentration (aldosterone ratio, AR) for lateralization Index (LI) was examined by Receiver operating characteristic (ROC) analysis. The predicting abilities of the ratio of aldosterone concentration between adrenal vein and IVC (aldosterone index, AI) and aldosterone concentration for selectivity index (SI) and contralateral ratio (CR) were also examined by ROC analysis. Results: Six samples (0.01%) with SI &lt;5 after ACTH stimulation those were determined unsuccessful AVS. The results of the area under the curve (AUC) in ROC analysis of aldosterone concentration and AI for prediction of SI&gt;5 was 0.998, 0.990, respectively, p=0.39. The optimal cut-off values of aldosterone concentration and AI for prediction successful AVS were 1700 pg/ml (sensitivity 99.5%, specificity 100%), 7.44 (sensitivity 94.0%, specificity 100%), respectively. Seventy-two patients (27.3%) had LI &gt;4 who were diagnosed as unilateral aldosterone excess. AR had 0.94 of AUC for prediction of LR &gt;4. The optimal cut-off value of AR was 3.53 (sensitivity 86.1%, specificity 94.8%). Eighty-two patients (31.1%) had unilateral CR&lt;1. The AUC of aldosterone concentration and AI for prediction of CR&lt;1 was 0.96, 0.98, respectively, p=0.07. The optimal cut-off values of aldosterone concentration and AI were 13600 pg/ml, 42, respectively. The sensitivity and the specificity at the optimal cut-off points of aldosterone concentration and AI were 91.5%, 91.5% and 91.5%, 94.8%, respectively. Conclusions: The determination of successful AVS and unilateral result in AVS can be predicted using aldosterone alone. It was suggested that AR is useful for tentative interpretation in the cases where the results of aldosterone were previously reported and lateralizing diagnosis of the cases with autonomous cortisol production.

scholarly journals Adrenocorticotropic Hormone–Stimulated Adrenal Venous Sampling Underestimates Surgically Curable Primary Aldosteronism: A Retrospective Cohort Study and Review of Contemporary Studies

Hypertension ◽  
2021 ◽  
Author(s):  
Nicholas Yozamp ◽  
Gregory L. Hundemer ◽  
Marwan Moussa ◽  
Jonathan Underhill ◽  
Tali Fudim ◽  
...  
Keyword(s):  
Primary Aldosteronism ◽  
Adrenocorticotropic Hormone ◽  
Adrenal Venous Sampling ◽  
Original Research ◽  
Venous Sampling ◽  
Acth Stimulation ◽  
The Past ◽  
Unilateral Disease ◽  
The Impact ◽  
Lateralization Index

Guidelines recommend adrenal venous sampling to determine disease laterality in primary aldosteronism. Adrenocorticotropic hormone (ACTH) stimulation clearly improves the likelihood of successful adrenal vein catheterization but may lead to a decrease in lateralization rates. To examine the impact of ACTH on lateralization, we performed a retrospective analysis of 340 patients with confirmed primary aldosteronism who underwent adrenal venous sampling with a single interventional radiology team using a protocol of sampling both before and after an ACTH bolus. In addition to this original research, we conducted a review of similar studies from the past 5 years to develop a consensus on the impact of ACTH on lateralization for primary aldosteronism. In the original research analysis, following a bolus of ACTH, 58% of patients had a decline in lateralization index which led to discordance between the pre-ACTH and post-ACTH classifications of lateralization in up to 26% of cases. The majority of discordant cases were due to reclassification from unilateral disease pre-ACTH to bilateral disease post-ACTH. In patients who already lateralized with unstimulated sampling, the response to ACTH did not have any impact on surgical outcomes. In a review of contemporary studies, we identified 11 similar studies in the past 5 years, of which 10 reported either no change or a decrease in lateralization index following ACTH, resulting in ≈25% discordance between unstimulated and stimulated lateralization rates. We conclude that ACTH stimulation during adrenal venous sampling can underestimate surgically remediable primary aldosteronism and recommend that the role of ACTH be limited primarily to enhancing selectivity.

43: The Utility of Adrenal Vein Sampling in Primary Hyperaldosteronism

2007 ◽  
Vol 177 (4S) ◽  
pp. 15-16
Author(s):  
Christopher H. Hawkins ◽  
Chandru P. Sundaram ◽  
Amy R. Qi ◽  
Matthew S. Johnson
Keyword(s):  
Primary Hyperaldosteronism ◽  
Adrenal Vein ◽  
Adrenal Vein Sampling

scholarly journals Adrenal Venous Sampling in Primary Aldosteronism: The Usefulness of Contralateral Suppression Index

2019 ◽  
Vol 2019 ◽  
pp. 1-4 ◽  
Author(s):  
Natalia Treistman ◽  
Aline Barbosa Moraes ◽  
Stéphanie Cozzolino ◽  
Patrícia de Fatima dos Santos Teixeira ◽  
Leonardo Vieira Neto
Keyword(s):  
Primary Aldosteronism ◽  
Vena Cava ◽  
Adrenal Vein ◽  
Adrenal Venous Sampling ◽  
Venous Sampling ◽  
Successful Cannulation ◽  
Contralateral Suppression ◽  
The Right ◽  
Cortisol Ratio ◽  
Suppression Index

Adrenal venous sampling (AVS) is the gold standard test to differentiate the unilateral from the bilateral form in patients with primary aldosteronism (PA) although it may be a difficult procedure, especially the successful cannulation of the right adrenal vein. In this report, we describe a 49-year-old female patient diagnosed with PA, after investigating resistant hypertension and refractory hypokalemia. Abdominal computed tomography scan revealed a 2.5 cm adenoma on the right adrenal vein. AVS was performed under cosyntropin infusion. Aldosterone and cortisol concentrations were obtained from the right and left adrenal veins and inferior vena cava (IVC). Cortisol on each adrenal vein divided by cortisol on IVC confirmed successful cannulation of the left side only, which makes it impossible to calculate the lateralization index (LI). From the data on the left adrenal vein and IVC, the aldosterone-to-cortisol ratio divided by the IVC aldosterone-to-cortisol ratio was less than 1.0, suggesting that the left adrenal vein was suppressed with the excess aldosterone originating from the contralateral side (contralateral suppression index (CSI)). Right adrenalectomy was performed; postoperative hypoaldosteronism was confirmed. This report highlights the importance of CSI obtained in AVS when technical difficulties occur making it impossible to obtain LI, which is most commonly used to decide between surgical and clinical management of PA.

ADRENAL VEIN SAMPLING WITHOUT DISCONTINUATION OF MINERALOCORTICOID RECEPTOR ANTAGONIST THERAPY

2020 ◽  
Vol 26 (9) ◽  
pp. 953-959
Author(s):  
Malini Ganesh ◽  
Shabirhusain S. Abadin ◽  
Leon Fogelfeld
Keyword(s):  
Plasma Renin Activity ◽  
Mineralocorticoid Receptor ◽  
Plasma Renin ◽  
Plasma Aldosterone ◽  
Adrenal Vein ◽  
Adrenal Vein Sampling ◽  
Mineralocorticoid Receptor Antagonist ◽  
Plasma Aldosterone Concentration ◽  
Contralateral Suppression ◽  
Lateralization Index

Objective: Guidelines recommend withdrawing mineralocorticoid-receptor antagonists (MRAs) for 4 weeks prior to adrenal vein sampling (AVS), but this is not always feasible because of hypertension and hypokalemia. This retrospective study of primary aldosteronism (PA) patients who underwent AVS between 2008 and 2018 assessed the effect of continuing MRA on the AVS procedure. Methods: Clinical data including antihypertensive regimen defined by the World Health Organization Daily Defined Dose (DDD) system were collected for 19 patients with adequate cannulation and lateralization during AVS. Results were compared between 5 patients who continued and 14 patients who discontinued MRA therapy (MRA and non-MRA groups). Results: At diagnosis, plasma renin activity, plasma aldosterone concentration (PAC), potassium (K) doses, and DDD were not significantly different between groups. Aldosterone-renin ratio was significantly higher in the MRA group (median, 375.0; interquartile range [IQR], 224.8 to 544.3 vs. 148.7, 118.4 to 192.1; P = .034). No difference was found in lateralization index (median 48.3; IQR, 23.6 to 52.1 vs. 8.7; 4.9 to 20.2; P = .10). Contralateral suppression, defined as aldosterone-cortisol ratio of unaffected adrenal to periphery, trended lower in the MRA group (median, 0.17; IQR, 0.03 to 0.39 vs. 0.51; 0.27 to 1.1; P = .056). All five MRA patients underwent successful adrenalectomy with at least 50% reduction in DDD and PAC and normal K postoperatively. One MRA patient did not lateralize, which was confirmed on repeat AVS, after MRA withdrawal. Conclusion: Continuation of MRA may not interfere with AVS lateralization or affect contralateral adrenal suppression. Continuation of MRA in preparation for AVS may be considered, especially in patients with severe PA, to avoid uncontrolled hypertension and severe hypokalemia. Abbreviations: ACTH = adrenocorticotropic hormone; APA = aldosterone-producing adenoma; ARR = aldosterone-renin ratio; AV = adrenal vein; AVS = adrenal vein sampling; CS = contralateral suppression; DDD = daily defined dose; IQR = interquartile range; K = potassium; LI = lateralization index; MRA = mineralocorticoid receptor antagonist; PA = primary aldosteronism; PAC = plasma aldosterone concentration; PRA = plasma renin activity

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